The Creation of the National Institute on Alcohol Abuse and Alcoholism: Responding to America's Alcohol Problem.

Although they had founded their own national society and their own treatment program, people recovering from alcoholism in the 1960's realized that Americans did not recognize the alcohol-dependent person's plight. Thus, a few dedicated individuals set out to establish, through Federal legislation, a nationwide effort to combat alcoholism.


PROBLEM problems in America:
The road to the passage and signing of this legislation was not easy.In the end, From the time the first colonists arrived in This complex set of problems over it required the courage of a number of the New World, bringing their alcoholic the past 150 years has been defined recovered alcoholics "going public," the beverages with them, Americans have had as a moral weakness problem and initiative and resourcefulness of a fresh a problem with alcohol.That problem is a turned over to the churches, defined man U.S. Senator (who persevered despite historic inability to reach any kind of a as an economic problem and turned a lack of funding for his Special Sub over to market and price control committee on Alcoholism), and the inter BRENDA G. HEWITT is special assistant to authorities, defined as a youth learn cession of three individuals in the waning the director of the NIAAA, Bethesda, ing problem and turned over to hours of New Year's Eve in 1970 to con Maryland.educators, defined as a crime prob The Creation of NIAAA lem and turned over to law enforce ment and correction agencies (U.S. Congress 1970, p. 115).
Several major shifts have occurred in the way Americans have perceived and responded to alcohol problems from the colonial era to the temperance era (includ ing Prohibition) and from the temperance and Prohibition era to the present (Moore and Gerstein 1981;Jung 1994).

The Colonial Era: Alcoholism Is a Sin
During the colonial period in America, alcohol was very much a part of a com munity's social life.Alcohol was used widely as both a beverage and a medicine, generally being considered a substance that was both enjoyable and healthful.Even drunkenness was tolerated so long as it did not interfere with a person's livelihood or religious observance.In the colonial view, the problem was not alcohol, but the indi vidual who used alcohol.Habitual drunken ness, which kept people from working and praying, represented a weakness of charac ter and a sin against God and the church.Punishment was colonial America's re sponse to such weakness, and the stocks (i.e., structures that confined the arms and legs of social miscreants for public chas tisement) were the colonial era's equivalent of the alcoholism treatment facility.

The Temperance Era: The Demon Is Rum
During the mid to late19th century, at tempts to respond to alcohol problems shifted from trying to control the individual to trying to control the substance.With the Nation's population transforming from an agrarian to an industrial society, new social problems, such as poverty and crime, began to emerge (Jung 1994).Each of these social ills was seen as connected to alcohol use.In response, a social reform movement was born that began to focus on eliminating alcohol use as a means of eliminating social problems.Aggressive public information and legislative activities of antialcohol groups, such as the American Temperance Society, 1 the Women's Christian Temper ance Union, and the AntiSaloon League, with their images of "demon rum" and axtoting women, helped change Americans' perceptions of alcohol problems and caused 1 The early temperance movement advocated "temper ate," or moderate, use of alcohol.This began to change to an antialcohol message around the 1850's.
them, in response, to consider eliminating the substance.Moore and Gerstein (1981) note that during this period, . . . the excessive drinker came to be seen as someone who was ravaged and transformed by an alien sub stance.Otherwise decent people could be transformed by drink to become dissolute, violent, or degen erate.Moreover, since alcohol was an addicting substance, even the most moderate drinker flirted with danger at the rim of every cup (p.9).
Although alcoholrelated health prob lems generally were not a major considera tion during the temperance era, there is some historical evidence that even during the hey day of the antisaloon leagues, some attention was given to the social and health conse quences of problem drinking.According to medical historian Phillip J. Pauly: In the early 1890's, Seth Low, a wealthy businessman, president of Columbia University and future mayor of New York [City], led the Sociology Group, an informal discussion circle of academic, commercial, and religious liberals interested in urban problems.In 1893 the group began to discuss alcohol, and became so persuaded of the need for knowledgeable, moderate action that they expanded to become a formal organization.The resulting Committee of Fifty for the Investigation of the Liquor Problem proposed to sponsor fact finding reports on the legal, eco nomic, ethical, and . . .physiologi cal aspects of alcohol use (Pauly 1990, pp. 366-392).
Not much came of the Committee's efforts as the national climate moved toward Prohibition, and 1919 saw the passage of the Volstead Act, ushering in the legal abolition of alcohol consumption.

Reaction and Inaction
Prohibition was both a success and a failure.According to the Cooperative Commission on the Study of Alcoholism, 2 on the one hand: . . .rates of problem drinking . . .decreased substantially during the early years of Prohibition. . . .reported deaths from liver cirrhosis also declined as did hospitalization for alcoholism.Arrests for public drunkenness were much lower than earlier (Plaut 1967, pp. 132-133).
On the other hand, "Prohibition was experienced as an intolerable abridgement of personal freedom by many Americans" (Plaut 1967, pp. 132-133).Thus, although Prohibition achieved the goal of reducing alcoholrelated problems, Americans found the loss of personal autonomy in the matter of alcoholic beverages excessive and voted to repeal the Volstead Act in 1932.
The experience of Prohibition led next to an era, from the 1930's through the 1960's, in which alcoholrelated problems generally were ignored.The Cooperative Commission aptly sums up the situation: The unique place of alcohol bever ages in American culture is evi denced by the fact that only one Amendment to the United States Constitution has ever been repealed; that was the Eighteenth, or Pro hibition, Amendment. . . .The Prohibition Amendment was an attempt to "legislate morals"; repeal of the Amendment was taken as evidence that the American people felt this attempt had not succeeded, or indeed, was an example of the medicine's being even worse than the illness.The hostile and apprehen sive reaction to this particular means of regulation has unfortunately been transferred to the general idea of a comprehensive approach [to alcohol problems].As a result, proposals to change drinking patterns-whether by educational, legislative, or other means-are still likely to evoke charge of disregarding the "lessons" of the Prohibition (Plaut 1967, pp. 14-15).
Fortunately, although many Amer icans tried very hard to forget about alcohol problems after Prohibition, changes were taking place in science and medicine, among public and private helping agencies, and, most importantly, among the group most affected by alcohol problems-the alcoholics themselves-to redefine alcoholrelated problems as health problems.

THE BEGINNING OF CHANGE
The private and public sectors undertook actions that revitalized the national debate about alcoholrelated problems and laid the groundwork for Federal legislation.In the private sector, both the founding in 1935 of the fellowship of Alcoholics Anonymous (AA) and the growing accep tance of alcohol abuse and alcoholism as health problems by scientific and medical organizations were pivotal events in helping to reintroduce the national policy debate on alcoholrelated problems.The success of AA helped to demonstrate that alcoholics could recover.The establish ment in the mid1930's of the Research Council on Problems of Alcohol at Yale University and the initial publication in 1940 of the scholarly journal Quarterly Journal of Studies on Alcohol were instru mental in recasting the public perception of alcohol abuse and alcoholism as problems that would yield to scientific solutions.The National Committee for Education on Alcohol (later called the National Council on Alcoholism), founded in 1944 by Marty Mann, the first woman to recover through AA, and researchers and physicians from Yale University, also helped to spread the word.By the 1950's major health care organizations, such as the American Medical Association and the World Health Organization, began to address the health care aspects of alcoholism and the discrim ination against alcoholics in health care settings.By the 1960's these groups were joined by the American Psychiatric Association and the American Public Health Association in declaring alcoholism an illness (Plaut 1967).On the public side, by this time several States, such as Cali fornia and Maryland, also had begun to develop programs to provide treatment and other supportive services to alcoholics, although these were often underfunded and not coordinated with the general health care system.
Despite these activities, public opinion was slow to move away from the view of alcohol abuse and alcoholism as moral or criminal issues.Federal programs to com bat alcohol problems also were limited.Additional information about the nature and causes of problem drinking is urgently needed.Past research in this area has been uneven and sporadic. . . .While special attention to alcohol prob lems is currently required . . .research in this field cannot be developed in isolation from inves tigations of a basic science nature and those on other medical and psychosocial problems (Plaut 1967, pp. 50 and 52).
There was a general feeling that the only way to sway public opinion and to address comprehensively alcohol abuse and alcoholism was from the national level through a highly placed and there fore highly visible Federal organization.For this, legislation was required, and it was to this end that the many disparate alcoholrelated organizations came to gether in 1968.
One person who was involved intimate ly in the struggle for Federal recognition of and support for alcoholism legislation was the late Thomas P. Pike, a wealthy busi nessman from Los Angeles, CA.In his Memoirs of Thomas P. Pike, Pike (1979), himself a recovering alcoholic, speaks of the man whose name was to become in delibly linked to P.L. 91-616: Then, in 1969, I met an extraordi nary man in Washington [DC] who convinced me that it was entirely possible to realize our "impossible dream" of reaching the many, sur mounting the huge barriers of public ignorance and ultimately changing societal attitudes and removing stigma from alcoholism. . . .This was the Honorable Harold Hughes, recovered alcoholic, former gover nor of Iowa, then a freshman U.S. Senator (Pike 1979, p. 237).
Immediately upon arriving in office, Senator Hughes was determined to move quickly in developing legislation address ing alcohol problems.To this end, he elected to take on the chairmanship in 1969 of a newly formed Special Sub committee on Alcoholism and Narcotics of the Senate Labor and Public Welfare Committee, even though funds were not available for its operation.Instead, Senator Hughes found a growing body of volun teers to do the work and donated his fees from speaking engagements to provide the necessary funding to bring the issues of alcohol abuse and alcoholism before both Congress and the American people.
The first hearing of the Special Sub committee on Alcoholism and Narcotics was held in Washington, DC, on July 30, 1969.Among those testifying at this event were Mann and Bill Wilson, one of the AA founders.According to Pike: Bill Wilson's testimony before the Senate Alcoholism Subcommittee was historic and it was electrifying.The members of the Subcommittee listened to him with respect and rapt attention as Bill sketched the history of AA, described alco holism as only he could, spoke of the desperate need for research and made an impassioned plea for long overdue and desperately needed Federal legislation and funding (Pike 1979, p. 240).
In 14 hearings held across the country during the summer of 1969, the Special Subcommittee received testimony from scientists, religious leaders, politicians, alcoholism treatment providers, and recovered alcoholics-individuals of disparate backgrounds who came together to tell the Nation that it was time to do something about the problems of alcohol abuse and alcoholism.
Based on these hearings, on May 14, 1970, Senator Hughes introduced into the Senate S. 3835, a bill intended to provide a comprehensive Federal program that would address the prevention and treat ment of alcohol abuse and alcoholism.At this point, the bill faced a long road to enactment.Not only did it need to pass both congressional houses, but it also had to be signed by President

House Approval
Despite this auspicious beginning, the timing of S. 3835's passage by the Senate late in the second session of the 91st Congress made final enactment even more uncertain.As the bill reached the House floor, a crowded December calendar threat ened to postpone its passage.If the House did not reach a decision by the end of its 1970 session, S. 3835 would have to begin the legislative process over again in the coming year.However, with the behind thescenes participation of a key Congress man, Pike managed to slip the bill into position for a vote "in the nick of time" (Pike 1979).A version of S. 3835 passed the House on December 15, placing the proposed NIAAA within NIMH instead of granting it independent status.Senator Hughes accepted the House version in the interest of time.S. 3835 had only one more hurdle before reaching enactment.

Enactment
Once more poised on the brink of success, those in the alcohol field were dismayed to learn that the new P.L. 91-616 might not become a "law of the land."Accord ing to Pike, members of President Nixon's cabinet had advised him to veto the bill.Pike, along with other influential partici pants in the movement to pass the legisla tion, 3 joined a concerted effort to persuade the President to sign this legisla tion into law."On New Year's Eve in 1970, President Nixon signed P.L. 91-616, which 3 Members of the movement who joined Pike in persuading the President included James Kemper, of the Kemper Insurance Company; Brinkley Smithers, of the Smithers Foundation; and Donald Kendall, of Pepsi Cola. 4 Author's Note: In reading the personal accounts of the late Thomas Pike, who participated in the Special Subcommittee hearings, and the record of those hearings, this is the only reference I have seen to P.L. 91-616 as the alcoholic's "Magna Carta."Most of the witnesses who testified before the Special Senate Subcommittee referred to P.L. 91-616 as the "Alcoholics' Bill of Rights."Given Pike's deep and abiding belief that alcoholics can be set free from their dependency, perhaps the use of Magna Carta as the quintessential basis for all human rights is the more appropriate analogy.
Pike called "a landmark in Public Health Legislation . ..[that] came to be known as alcoholism's Magna Carta" (Pike 1979,  p. 241). 4 There was no public ceremony.Very few people outside the nascent alcohol field were aware that history was being made.Yet December 31, 1970, marked not a year's ending but an Institute's beginning.

P.L. 91-616: THE CREATION OF NIAAA
The landmark legislation that created NIAAA represented to many in the alco hol field a point of culmination in the history of Americans' answers to the alcohol problem.In his foreword to the First Special Report to the U.S. Congress on Alcohol and Health issued in December 1971, Secretary of Health, Education, and Welfare (HEW) Elliot L. Richardson noted: We have emerged from an era when alcohol abuse and alcoholism were equated by the public with moral degeneration and despair to the day in 1970 when President Nixon signed into law the landmark Public Law 91-616. . . .This law followed a historical precedent of bringing together diverse and often divided interests in our society in support of a major public health measure (NIAAA 1973, p. V).
NIAAA's Mission.P.L. 91-616 estab lished NIAAA as an organizational com ponent of NIMH and instructed NIAAA to . . .develop and conduct compre hensive health, education, research, and planning programs for the prevention and treatment of alcohol abuse and alcoholism and for the rehabilitation of alcohol abusers and alcoholics (P.L. 91-616, p. 1).
In addition to creating NIAAA, P.L. 91-616 did the following: • Required that alcoholism programs be made available to Federal civilian employees • Authorized the appropriation of Federal funds to the States via a for mula grant mechanism to assist them in planning, establishing, maintaining, coordinating, and evaluating projects for the development of more effective prevention, treatment, and rehabilita tion programs • Prohibited discrimination in the hiring and firing of recovered alcoholics in nonsecurity jobs • Authorized grants and contracts for education and training purposes and for demonstration and evaluation projects that provide treatment and prevention services • Required the admission of alcohol abusers and alcoholics to any public or private general hospital receiving Federal funds for alcoholism treatment programs on the basis of medical need, and prohibited discrimination against this population solely because of their alcoholism • Required that the records of patients in alcoholism treatment be kept confidential

INDEPENDENCE
Members of the alcohol movement who felt strongly that the needs of alcoholic persons would not receive the national attention and priority necessary to effect change if NIAAA remained under the mental health mantle continued to push for NIAAA's independent status.Even before P.L. 91-616 was enacted, many organizations supporting the law had The National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) placement within the Department of Health, Education, and Welfare's Public Health Service.In 1974 NIAAA became an Institute independent from the National Institute of Mental Health.

Figure 1
Health Services and Mental Health Administration favored placing NIAAA on its own with in HEW's U.S. Public Health Service (Lewis 1988).Although Senator Hughes had accepted the House's placement of NIAAA within NIMH in 1970, NIAAA's autonomy had been his original intention in S. 3835.Thus, the stage was set for yet another major event in NIAAA's historyits elevation from an Institute of NIMH to a fully autonomous Institute of the newly created Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA; figure 1).
This reorganization occurred when NIAAA's 3year authorization went before Congress for renewal in 1973 and resulted in P.L. 93-282, the Compre hensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act Amendments of 1974.These Amend ments placed NIAAA, NIMH, and a new National Institute on Drug Abuse as equal partners under ADAMHA (figure 1).
In his preface to the proceedings of NIAAA's Third Annual Alcoholism Conference, thenNIAAA director Morris Chafetz noted that "This time the signing took place-not in the dark stillness of the night-but in the bright ceremonial at mosphere of the Oval Office" (Chafetz 1974, p. iii).To many, the creation of a separate, visible national Institute devoted to addressing comprehensively the prob lems of alcohol abuse and alcoholism was the true ending of the story that had begun some 35 years ago.

EPILOGUE
Since the passage 25 years ago of P.L. 91-616, NIAAA's mission has evolved significantly.Changes have occurred in its leadership, its organizational home, and its primary program emphasis.True to the legacy of P.L. 91-616, however, NIAAA's commitment to discovering the best ways to prevent and treat alcohol abuse and alcoholism in America still embodies the strong hopes and dedication of those who fought for this Institute's creation and who helped to define alcohol abuse and alco holism not as problems experienced by a few but as a national problem.■

2
The Cooperative Commission on the Study of Alco holism was established by a grant from the National Institute of Mental Health in 1961.It was the first national body established by the Federal Government to assess what the country was doing to respond to alcohol problems and to recommend ways to improve existing alcoholrelated policies and programs.
By the 1960's the National Institute of Mental Health (NIMH) in the U.S. Public Health Service had begun a very small program of grants in the alcohol area, leading to the establishment in 1965 of the National Center for the Prevention and Control of Alcohol Problems as a component of NIMH, with limited program authority and a limited budget.The situation with research was even more dismal.As assert ed by the Cooperative Commission on the Study of Alcoholism in its 1967 report: